Table 3 List of recommendations for preadmission and preoperative care

 We recommend fully evaluating patients with lung cancer who are potential candidates for curative surgical resection, regardless of age. However, age itself is a risk factor included in two mortality risk scores after thoracic surgery, and should be taken into account to estimate the perioperative risk.

Fair

A

 We recommend that patients with ASA class ≥ 3 should be considered at higher risk of developing postoperative complications.

Good

A

 In obese patients, we recommend specific care for airway management, with proactive strategies to reduce the risk of cardiovascular, endocrine, metabolic, and infective complications; any effort can be fruitful, including special attention to patient-related factors. Pre-operative screening of obstructive sleep apnea (OSA) by means of validated questionnaires is suggested in high-risk obese patients, with the aim of implementing strategies to reduce perioperative and postoperative complications. The perioperative team should focus on strategies to reduce the risk of complications for patients with body mass index ≥ 30 kg/m².

Good

A

 We recommend identifying the patients with preoperative abnormal serum creatinine and glomerular filtration rate as high-risk patients, and implementing prophylactic strategies against acute kidney injury in these patients. Hemodialysis is not an absolute contraindication to lung resection for non-small cell lung cancer. Careful monitoring of metabolic and hematologic parameters, and prompt and aggressive treatment of complications, is recommended in the perioperative period.

Poor

A

 We recommend a smoking cessation period in current smokers with lung cancer who are potential candidates for curative surgical resection. An optimal interval of cessation has not been clearly identified. Nonetheless, given that smoking status is a strong predictor of postoperative lung complications, we suggest smoking cessation at least 2–3 weeks before surgery (ideally 4 weeks before).

Fair

A

 Alcohol abuse in patients undergoing lung cancer surgery is associated with increased postoperative pulmonary complications and mortality, and reduced long-term survival. In alcohol abusers, we recommend cessation of alcohol consumption at least 2–3 weeks before surgery (ideally 4 weeks before).

Fair

A

 We recommend a careful preoperative cardiac evaluation—including clinical scores—in order to identify potential cardiac risk factors. Recognition of these factors allows stratification of perioperative risk, optimization of medical treatment, perioperative planning and an overall reduction in morbidity.

Fair

A

 We recommend measuring both ppoFEV₁ and ppoDLCO during preoperative respiratory risk evaluation. ppoFEV₁ and ppoDLCO levels of 40% are considered the lower limits for safe lung surgery, except in selected cases (lung volume reduction effect) where a lower threshold (ppoFEV₁ and ppoDLCO = 30%) may be considered. Because ppoFEV₁ and ppoDLCO are not always accurate predictors of postoperative function and outcome, we recommend the use of a larger panel of exercise tests in patients with values < 40% to evaluate risk according to guidelines for the preoperative evaluation of lung resection patients.

Fair

A

 VO2max evaluation is recommended to stratify perioperative respiratory risk. Patients having a VO2max > 20 mL/kg/min are regarded as being at low risk of pulmonary complications, and are deemed fit for major surgery. It is recommended that patients having a VO₂max < 10 mL/kg/min should be counseled about minimally invasive surgery, sublobar resections or nonoperative treatment options. Patients having a VO₂max between 10 and 20 mL/kg/min require further multi-dimensional steps for the stratification of respiratory risk. (Lower technology tests, such as the stair-climbing test or the shuttle walk distance, may be used instead of CEPT, but the quality of evidence is lower.)

Fair

A

 Arterial blood gas analysis should be performed in all patients scheduled for an elective pulmonary resection as part of the basic pulmonary function tests.

Fair

A

 We recommend evaluating diabetes and assessing preoperative nutritional status (including weight loss) to estimate the surgical risk of patients undergoing thoracic surgery.

Fair (diabetes evaluation)

Good (preoperative nutritional assessment)

A

 Preoperative risk stratification aims at identifying high risk surgical patients (e.g., those with ASA ≥ 3, advanced cardiac disease, renal failure, VO₂max < 10 mL/kg/min, ppoFEV₁ or ppoDLCO < 40%, systemic disease, or other risk factors). In these patients, multidisciplinary assessment is useful to consider different treatment options and select the best therapeutic approach.

Poor

A

 We recommend preoperative exercise rehabilitation in candidates for curative surgical intervention for lung cancer as it may reduce postoperative pulmonary complications. Since prehabilitation may reduce length of stay and postoperative pulmonary complications, it may be useful in COPD patients with mild to severe airway obstruction. Multimodal prehabilitation (early functional respiratory evaluation, smoking cessation, respiratory rehabilitation, nutritional status, physical exercise) is more effective than unimodal prehabilitation. It is advisable to schedule a preoperative prehabilitation program of 3 weeks.

Poor

A

 Patients’ engagement has proven benefits on both clinical outcomes and healthcare sustainability. We suggest a patient Health Engagement (PHE) model to monitor patients’ engagement and psychological needs and expectations.

Fair

B

 We recommend the video-assisted thoracoscopic approach for lung surgery whenever possible, because of the lower incidence of postoperative complications, shorter length of hospital stay and lower levels of postoperative pain associated with this technique.

Good

A

 We do not recommend preoperative mechanical bowel preparation in patients undergoing lung surgery.

Poor

D

 We recommend limiting clear fluid and solid fasting up to 2 and 6 hours, respectively, in patients undergoing lung surgery who are not at risk of delayed gastric emptying.

Good

A

 We recommend preoperative carbohydrate loading with clear fluids up to 2 h prior to surgery for patients undergoing lung surgery, especially malnourished patients, in order to reduce perioperative discomfort and insulin resistance.

Poor

A

 We suggest avoiding the routine use of benzodiazepines before thoracic surgery, especially in elderly people. When used in selected cases, short-acting benzodiazepines should be preferred over long-acting agents.

Fair

B